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2. Personal or Business*

   1. Personal

   1. Business
4. Tenant Name*

6. I, (Tenant), hereby acknowledge the following:

   1. I have entered into a rental agreement or lease for the dwelling located at:

8. Address*
10. City*
11. State*
12. Zip Code*
16. Mail bills to (only if different from above):
18. Mailing Address
20. City
21. State
22. Zip Code

26. 2. I am in good standing with the Water Division and I am current with all my obligations to the Village of Hanover Park, including but not limited to past water bills at other Hanover Park address locations.

    3. I have entered into a rental agreement/lease with the owner/landlord for the above identified dwelling unit. The rental agreement/lease states that I am responsible for all water and sewer bills, and that the water service is not included in the rent.

    4. I have read and understand the Village of Hanover Park water policy as enumerated in Hanover Park, IL Code Chapter 106.

    5. I authorize the Village to maintain me as an "Associated Customer" for the water and sewer account, and that I agree to assume the responsibility for the water and sewer bills. I further agree, defend, indemnify, and hold the Village, its officers, officials, and employees harmless from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or in connection with the Landlord and Tenant Agreement of Tenant Responsibility and the Village of Hanover Park Water Policy.

28. Tenant Name*
30. Tenant Phone Number*
32. Tenant E-mail*
34. Driver's License Front*
35. Business Federal Employer Identification Number*
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field